Musculoskeletal pain in primary health care: A biopsychosocial perspective for assessment and treatment

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Musculoskeletal pain in primary health care:

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To my beloved grandchildren Lucas, Julia, David, Tilda and Märta

Hold fast to dreams For if dreams die

Life is like a broken-winged bird That cannot fly

Hold fast to dreams For when dreams go Life is a barren field Frozen with snow

Langston Hughes 1902-1967

Örebro Studies in Medicine 40

Anders Westman

Musculoskeletal pain in primary health care:

A biopsychosocial perspective for assessment

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To my beloved grandchildren Lucas, Julia, David, Tilda and Märta

Hold fast to dreams For if dreams die

Life is like a broken-winged bird That cannot fly

Hold fast to dreams For when dreams go Life is a barren field Frozen with snow

Langston Hughes 1902-1967

Örebro Studies in Medicine 40

Anders Westman

Musculoskeletal pain in primary health care:

A biopsychosocial perspective for assessment

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© Anders Westman, 2010

Title: Musculoskeletal pain in primary health care:

A biopsychosocial perspective for assessment and treatment

Publisher: Örebro University 2010

www.publications.oru.se

Editor: Heinz Merten

heinz.merten@oru.se

Printer: intellecta infolog, Kållered 02/2010

issn 1652-4063 isbn 978-91-7668-716-1

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© Anders Westman, 2010

Title: Musculoskeletal pain in primary health care:

A biopsychosocial perspective for assessment and treatment

Publisher: Örebro University 2010

www.publications.oru.se

Editor: Heinz Merten

heinz.merten@oru.se

Printer: intellecta infolog, Kållered 02/2010

issn 1652-4063 isbn 978-91-7668-716-1

ABSTRACT

Westman, A (2010): Musculoskeletal pain in primary health care: A biopsychosocial perspective for assessment and treatment.

Long-term musculoskeletal pain is a large public health problem with serious conse-quences for both the individual and society. Psychosocial factors have been shown to be good predictors of long-term disability and play an important role in the transition from acute to chronic pain. Early identification and intervention of those that run the risk of developing long-term disability would offer a great opportunity for reducing costs and personal suffering. The overall aim of this thesis was to assess a biopsychosocial approach to the assessment and management of musculoskeletal pain patients in pri-mary health care.

To this end, biopsychosocial assessment and treatment methods were tested in two different populations of primary care patients suffering pain. Results indicated that improvements in quality of life and work capacity one year after early multimodal rehabilitation were basically maintained after five years. The most salient prognostic factors determining return to work were educational level and the individual’s perceived health (Study I). Psychosocial factors as measured by the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) were related to disability and perceived health three years after treatment for non-acute pain problems (Study II). The experimental group in the controlled multimodal pain rehabilitation programme had lower health care utiliza-tion and a reduced risk of using large amounts of medicautiliza-tion after three years compared with the participants in the control group. However, there were no significant differ-ences between the groups on variables such as work capacity, function, catastrophizing and pain (Study III). Distinct profiles of catastrophizing, fear-avoidance beliefs, and distress were extracted and meaningfully related to future sick leave and dysfunction (Study IV).

Our findings provide support for the biopsychosocial model and highlight the im-portance of psychosocial factors in long-term outcome. The results underscore the need for early identification of patients at risk. Further, multimodal treatment that covers not only biological but also psychosocial factors seems to be a key to successful treatment, and ideally this intervention should be matched to the patients’ needs.

Keywords: musculoskeletal pain, biopsychosocial, multimodal, fear-avoidance, catastrophizing, distress, sick leave, function.

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PUBLICATIONS

This thesis is based upon the following papers, which are referred to in the text by the corresponding Roman numerals:

I. Westman A, Linton S J, Theorell T, Öhrvik J, Wahlén P, Leppert J.

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up.

Disabil Rehabil, 2006. 28(7): 437-446.

II. Westman A, Linton S J, Öhrvik J, Wahlén P, Leppert J.

Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain? A validation of the Örebro Musculoskeletal Pain Screening Questionnaire.

Eur J Pain, 2008. (12):641-649.

III. Westman A, Linton S J, Theorell T, Öhrvik J, Wahlén P, Leppert J.

Controlled 3-year follow-up of a multidisciplinary pain rehabilitation programme in primary health care.

Disabil Rehabil, 2010. 32(4): 307-316.

IV. Westman A, Boersma K, Leppert J, Linton S J.

Avoidance beliefs, catastrophizing and distress – a longitudinal subgroup analysis on patients with musculoskeletal pain (MSP).

Submitted to the Clinical Journal of Pain.

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ABBREVIATIONS

ADL Activities of daily living

BPS Biopsychosocial

CBT Cognitive behavioural therapy

CHAMP The Center for Health and Medical Psychology

CNS Central nerve system

CKF Centre for Clinical Research

CSQ Coping Strategies Questionnaire

CI Confidence interval

DRI Disability Rating Index

EPM Psychosomatic Medicine Clinic

GCT Gate control theory

GLM General Linear Model

GP General practitioner

HPA Health profile assessment

HAD HAD Hospital Anxiety and Depression

IASP International Association for the Study of Pain

MSP Musculoskeletal pain

OR Odds ratio

QL Quality of life

PCS Pain Catastrohizing Scale

PHC Primary health care

ROC Receiver operator characteristic

RCT Randomized controlled trial

SD Standarad deviation

SPSS Statistical Package for the Social Sciences

SF-36 Medical Outcomes Study Short-Form Health Survey 36

TSK Tampa Scale for Kinesiophobia

TSK-SV Tampa Scale for Kinesiophobia-Swedish Version

ULF National Living Survey

VAS Visual analogue scale

ÖMPSQ Örebro Musculoskeletal Pain Screening Questionnaire

PREFACE

As a physician in family medicine, occupational health and, subsequently psycho-somatic medicine, when thinking of the “stream” of patients I have met over the years I have become increasingly amazed at the close connection between body and mind. The geneses to a patient’s problems are often multifactorial, and there are continuous ongoing interactions between these various factors in the processes of illness, recovery and the preservation of health. There remain, however, influences of dualism and reduc-tionism in the health care system which obstruct the possibility of meeting patients needs in an optimal manner. This thesis has grown from a personal desire to propose a more holistic approach towards the management of pain patients in primary health care.

An old oriental metaphor describes a human being as a carriage consisting of a horse, a cart, a driver and a passenger.

Image adapted from Mobilus Professional

This image distinguishes between two bodily elements: the material body (the “corpse” in us) and the physiological processes (the life in us). The two mental elements repre-sent the psychological functions (thoughts, feelings) and the spiritual spark of self-awareness (the “I am” in us). In this picture, the material body is symbolized by the cart and the living processes by the horse, pulling the cart. The psychological functions are seen as the driver leading the horse. The passenger, sitting in the centre, aware of the whole carriage but also the surroundings, directs the driver who carries out his orders. The passenger is the self-awareness of “I am” and the whole carriage, e.g. the human

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Musculoskeletal pain in primary health care… ✍

anders westman

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Health profi le assessment (HPA) ...34

Patient satisfaction ... 35

The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) ... 35

Coping ... 35

Life events ...36

Health care utilization ...36

Drug consumption ...36 Psychosomatic symptoms ...36 Fear-avoidance beliefs ...36 Catastrophizing ...36 Distress ...37 Statistics ...37 Study I ...37 Study II ...37 Study III ...38 Study IV ...38 Results...41

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up (Study I) ...41

Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain? A validation of the Örebro Musculoskeletal Pain Screening Questionnaire (Study II) ...43

Controlled 3-year follow-up of a multidisciplinary pain rehabilitation program in primary health care (Study III) ... 45

Avoidance beliefs, catastrophizing and distress: A longitudinal subgroup analysis on patients with musculoskeletal pain, (MSP), (Study IV). ...47

General discussion ...53

Limitations and strengths ...57

Clinical implications ...59 Future implication ...60 Conclusions ...63 Acknowledgments ...65 References ...69 11

PREFACE

As a physician in family medicine, occupational health and, subsequently psycho-somatic medicine, when thinking of the “stream” of patients I have met over the years I have become increasingly amazed at the close connection between body and mind. The geneses to a patient’s problems are often multifactorial, and there are continuous ongoing interactions between these various factors in the processes of illness, recovery and the preservation of health. There remain, however, influences of dualism and reduc-tionism in the health care system which obstruct the possibility of meeting patients needs in an optimal manner. This thesis has grown from a personal desire to propose a more holistic approach towards the management of pain patients in primary health care.

An old oriental metaphor describes a human being as a carriage consisting of a horse, a cart, a driver and a passenger.

Image adapted from Mobilus Professional

This image distinguishes between two bodily elements: the material body (the “corpse” in us) and the physiological processes (the life in us). The two mental elements repre-sent the psychological functions (thoughts, feelings) and the spiritual spark of self-awareness (the “I am” in us). In this picture, the material body is symbolized by the cart and the living processes by the horse, pulling the cart. The psychological functions are seen as the driver leading the horse. The passenger, sitting in the centre, aware of the whole carriage but also the surroundings, directs the driver who carries out his orders. The passenger is the self-awareness of “I am” and the whole carriage, e.g. the human

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INTRODUCTION

“The assessment and treatment of chronic and frequently recurring pain conditions are one of the most difficult areas of medicine………There are few areas in which a holistic approach is as important as when it comes to helping people with chronic pain…..”

National Board of Health and Welfare, 1994.

Pain from a historical perspective

Given the universal nature of pain, various scholars have attempted to understand and explain its experience throughout history. Plato (ca 427-347 BC) believed that the heart and liver were centres for the appreciations of all sensation, and that pain arose not only from peripheral sensation but as an emotional response in the soul, which resided in the heart. Hippocrates (ca 460-370 BC) considered the mind and body as one unit but asserted that pain was the result of an imbalance in vital fluids. Aristotle (ca 384-322 BC), on the other hand, asserted that pain was due to the gods and evil spirits which entered the body via an injury. The brain was not believed to have any direct influence and, for years, the heart was considered to be the centre of pain sensation.

The biomedical model

René Descartes (1596-1650), the foremost philosopher of the Renaissance, offered a dualistic view of mind and body. The pain model of Descartes, commonly known as Cartesian or the biomedical model, is the one on which our modern health care system is built. The model is mechanistic, with the underlying message that pain is the direct product of a noxious stimulus activating a dedicated pathway from the skin along nerve fibres, to the centre of the brain where it activates a mechanical behaviour response. The biomedical model, with its strong emphasis on biology, has serious limitations and its character is to a great extent reductionistic. The school medicine is mainly influenced by this dualistic model, and physicians and other medical personnel are still educated within this reductionistic paradigm. Primary care physicians are working daily to relieve patient symptoms for which they cannot determine an exact pathoanatomical diagnosis. Moreover, treatment routines usually have a biomedical approach and, in many cases, it is difficult to tailor treatment to the needs of the individual patient.

Definitions and classifications

The established definition of pain according to IASP (the International Association for the Study of Pain) is “an unpleasant sensory and emotional experience associated

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INTRODUCTION

“The assessment and treatment of chronic and frequently recurring pain conditions are one of the most difficult areas of medicine………There are few areas in which a holistic approach is as important as when it comes to helping people with chronic pain…..”

National Board of Health and Welfare, 1994.

Pain from a historical perspective

Given the universal nature of pain, various scholars have attempted to understand and explain its experience throughout history. Plato (ca 427-347 BC) believed that the heart and liver were centres for the appreciations of all sensation, and that pain arose not only from peripheral sensation but as an emotional response in the soul, which resided in the heart. Hippocrates (ca 460-370 BC) considered the mind and body as one unit but asserted that pain was the result of an imbalance in vital fluids. Aristotle (ca 384-322 BC), on the other hand, asserted that pain was due to the gods and evil spirits which entered the body via an injury. The brain was not believed to have any direct influence and, for years, the heart was considered to be the centre of pain sensation.

The biomedical model

René Descartes (1596-1650), the foremost philosopher of the Renaissance, offered a dualistic view of mind and body. The pain model of Descartes, commonly known as Cartesian or the biomedical model, is the one on which our modern health care system is built. The model is mechanistic, with the underlying message that pain is the direct product of a noxious stimulus activating a dedicated pathway from the skin along nerve fibres, to the centre of the brain where it activates a mechanical behaviour response. The biomedical model, with its strong emphasis on biology, has serious limitations and its character is to a great extent reductionistic. The school medicine is mainly influenced by this dualistic model, and physicians and other medical personnel are still educated within this reductionistic paradigm. Primary care physicians are working daily to relieve patient symptoms for which they cannot determine an exact pathoanatomical diagnosis. Moreover, treatment routines usually have a biomedical approach and, in many cases, it is difficult to tailor treatment to the needs of the individual patient.

Definitions and classifications

The established definition of pain according to IASP (the International Association for the Study of Pain) is “an unpleasant sensory and emotional experience associated

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men and 68% of women stated that they had persistent aches and pain in the back, neck, shoulders, elbows, legs or knees. Persistent aches and pain, however, have become more common since the early 1980s, particularly among women and young people [119]. The point prevalence of back disorders (i.e. the percentage who report back problems when asked) has been found to vary in Europe from a low of 14-15% in Great Britain and Denmark to a high of 31% in Sweden, Finland and Germany [160, 164]. The majority of patients presenting, for example, acute low back pain (LBP) have at least one recur-rence of it in the following year and most patients continue to have episodes of signifi-cant pain and disability [118]. International surveys of LBP report a lifetime prevalence of about 60-70% [111].

Musculoskeletal symptoms of various types are a major reason for consultation in primary care. In Scandinavia, 20-40% of visits to general practitioners (GPs) consist of pain problems [55, 94, 124]. Long-lasting pain problems are associated with an increased utilization of health care; a Swedish study showed that about 40% of patients with chronic pain have consulted a GP during the last three months [3, 13]. On an indi-vidual level, persistent musculoskeletal pain significantly affects a patient’s quality of life, e.g. the pain is usually continuous and impairs a variety of functions. Not all patients, however, develop chronic problems and only a small percentage (3-10%) ex-perience a long-term absence from work. This small number of patients nevertheless consume about 75-85% of the available resources [162].

In many cases involving musculoskeletal pain, it is a problem to establish a specific diagnosis and the origin of a patients’ symptoms remain unknown. International epide-miological studies have shown that a substantial proportion of patients in primary care complain of physical symptoms not attributable to any known conventionally defined disorder, i.e. they suffer from medically unexplained or functional somatic symptoms [38, 127]. Clinical experience and recent research has shown that our highly specialized health care systems often have a problem handling these types of patients success-fully[113, 129, 143]. For the individual patient and the health care provider this is often frustrating and frequently the patient will be sent on an almost endless pursuit of medical interventions [82]. Furthermore, patients with an unclear diagnosis experience negative treatments, insufficient contact with clinicians and distrust throughout the consultation process [69]. On the other hand, the physicians themselves may experience an “angry helplessness” towards their patients leading to feelings of low satisfaction with themselves and of a deficiency to communicate with their clients [96].

Pain and disability are obviously related to each other and, in clinical practice, they are often treated as being equivalent. They are not equivalent, however, and it is impor-tant to make this distinction. Epidemiological research indicates that whereas 40% of people in the community report having chronic pain a much smaller portion in the definition underscores both the subjectivity of pain and the importance of emotional as

well as sensory factors. Thus, pain is recognized to have many dimensions. It includes psychological as well as biological factors and is truly a multidimensional phenomenon. It is worth considering that pain is always a personal and subjective experience which, taken as a whole, makes it unquestionable. As a consequence, our ability to measure pain with obvious objective methods is restricted.

Chronic pain has been defined as “that which persists beyond the normal time of

healing” and three months is considered “the most convenient point of division between acute and chronic pain, but for research purposes six months will be preferred” IASP

(1994). Persistent pain is defined as pain that was present “most of the time for a period

of six months or more during the prior year” [51].

Gender differences and musculoskeletal pain

Average life expectancy in Sweden, as in many western countries, is higher for women than for men. Women, however, are seeking care at higher rates than men and muscu-loskeletal pain problems are more common among women [8, 47, 110, 153]. Further-more, a women’s pain is classified as medically unexplained more often then a man’s [142, 168]. The reason for the difference is probably complex, including both biological and social mechanisms. Genus, rather than sex, may be an important factor for how pain is perceived and interpreted and for which consequences pain may have [37, 165].

Musculoskeletal pain and disability in primary health care

Over the last few decades many disciplines have contributed to the development of a multidimensional understanding of causality in chronic pain. Pain is the most common symptom in health care but, despite this, perhaps one of the least understood. Although many pain problems are acute and short-lived, as is most often the case, pain may be ongoing with chronic illnesses. Chronic pain is often difficult to diagnose and treat because it is simultaneously “subjective” and “objective” and arises as a consequence of interactions between physical, emotional, cognitive, and behavioural variables [84]. Pain is a symptom which originates from a great number of conditions and is not equivalent with either diagnosis or disease. The current view is that no causal relation-ships exist between pathophysiology or tissue damage on one hand and subjectively reported pain on the other hand. [155]. There is a consensus today that chronic pain cannot be considered as a purely biomedical phenomenon but nor can it be regarded solely as a result of psychological factors and conditions.

Epidemical studies from Sweden have shown pain prevalence rates of 35-65% [2, 8, 19, 47] with musculoskeletal pain representing the majority of persistent pain. Statistics taken from Sweden's Survey of Living Conditions (ULF) for 2002-03 show that 57% of

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